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This is a personal view on the implications for mental health services of the Executive Letter of the National Health Service Management Executive (NHSME), published in July 1992 (EL (92) 48): ‘Guidance on the extension of the Hospital and Community Health Services elements of the GP Fundholding Scheme from 1st April, 1993’.

In mid-1991, the Conference of Medical Royal Colleges and their Faculties initiated an Advisory Group on Information Services with broad representation from the profession, the NHS Management Executive, and the Department of Health. The aim of the group is to facilitate and co-ordinate input from the profession to the NHS Information and Technology Strategy. It is chaired by Sir Duncan Nichol, NHS Chief Executive.

Concern is increasingly being expressed about the lack of provision for mentally disordered offenders, who by default end up within the penal system. Gunn et al (1991) in a study of sentenced prisoners identified a significant number who were mentally disordered to be in need of psychiatric treatment. Among these, 0.4% were considered to be mentally handicapped. Recent reports have emphasised the importance of diverting these individuals from the criminal justice system (Woolf & Tumin, 1991; Home Office, 1990; British Medical Association, 1990). However, the majority of such offenders do not fulfil the criteria for admission to hospital under the Mental Health Act 1983. Most are not overtly mentally ill and do not require treatment in conditions of medium security such as exist in regional secure units. However, it is not clear what provision there should be for such individuals. Smith (1988) described an open forensic unit for mildly mentally handicapped offenders (the Leander Unit). She concluded that there was a need for a specialised service to cater for these patients, who were neither appropriately nor adequately provided for by the general psychiatric services, the mentally handicapped services, regional secure units or special hospitals. Unfortunately, in practice there are very few facilities for this group of patients.

This paper aims to give a very brief outline of the vast subject of hypnosis in the context of psychiatry. The word hypnosis, which was derived from Hypnos meaning the God of sleep, has long been associated with magical practices, superstition, witchcraft, occult and many other esoteric practices. The forerunner of hypnosis was the theory of animal magnetism proposed by Franz Anton Mesmer in the 1770s. He began to experiment with magnetic metals and gradually elaborated the theory of animal magnetism. According to Mesmer, a magnetic fluid spread throughout the entire universe and its disturbed balance in the human body resulted in illness. He claimed that a beneficial magnetic fluid could be transmitted from one subject to another by ‘passes’. Braid (1843) refuted the fluidist theory, since according to him hypnosis could be induced by visual fixation. He believed the condition to be a form of sleep and called the technique neurypnology, later to become hypnology and hypnosis. Liebeault (1866) for the first time used verbal suggestion to induce hypnosis. Bernheim stated that “There is no such thing as hypnotism, there is only suggestibility”, and concluded that suggestibility was the process by which the brain “accepts the idea and transforms it into action”.

The Access to Health Records Act came into force on 1 November 1991. This legislation allows patients access to their written medical records (access to computerised records is covered by separate legislation). Concerns have been expressed about the implications of this Act for staff and patients, particularly in psychiatry. These concerns have included detrimental effects on patients exposed to their notes and the restrictions it could place upon staff in recording speculation or subjective opinion. We report the following findings: staff attitudes to the new legislation including awareness of the Act, evaluation of the Act as useful or detrimental and the Act's implications on clinical practice.

Few clinical decisions are more difficult than whether or not to withhold treatment from patients who are unable to make this choice for themselves. This is because they bring into conflict a number of principles central to clinical practice, such as the duty to save life, the duty to relieve suffering, and the duty to heed patients' wishes. In North America, advance directives (‘living wills’) from patients, made when they are fully competent, have achieved considerable popularity in recent years as a possible way out of these dilemmas (La Puma et al, 1991; Molloy et al, 1991); unfortunately, it is by no means clear whether these can in fact provide a workable solution to the problem of treating incompetent patients (Hope, 1992). For the time being, decisions about withholding treatment will continue to be made by the health professionals immediately involved at the time, often junior staff with little experience or training, and there is a need for a professional consensus as to the factors that should be properly taken into consideration. This study investigates the current attitudes and approaches of psychiatrists and psychiatric nurses in one health district to this problem. It examines the criteria used, and the conditions under which decisions about administering or withholding treatments are being made.

Old age psychiatry has been steadily developing as a specialty in the United Kingdom. In 1978 the Royal College of Psychiatrists established a specialist section for old age psychiatry, and since October 1989 it has been formally recognised as a sub-specialty of psychiatry. In 1989 the Royal College of Physicians and the Royal College of Psychiatrists published a joint report entitled ‘Care of Elderly People with Mental Illness’ in which recommendations were made about both postgraduate and undergraduate training.

The development of hospital hostels was advocated by the DHSS in 1975. These combined the clinical expertise and back-up of hospital resources with a domestic environment. The suggested level of provision was eight to ten places per 200,000 population in areas of average need and ten to 12 places in high need areas.

Recent ministerial statements and health circulars have identified a key role for the NHS in providing services for people with a learning disability who have a mental illness or a severe behaviour disorder (NHS Management Executive, 1992). This is not an insignificant task, given that psychiatric disorders (including both mental illness and/or severe behaviour disorders) occur among approximately 30% of people with a moderate or severe learning disability (Corbett, 1979; Lund, 1985). Patients with psychiatric disorders have proved particularly difficult to resettle from mental handicap hospitals, and form a substantial proportion of the patients who become long-stay residents of mental handicap hospitals despite the development of community-based services. It is therefore essential that each district health authority defines the most appropriate pattern of services for this group of patients, as part of their purchasing strategy for mental health. The type of service required was discussed by the department of Health report Needs and Responses: Services for Adults with Mental Handicap who are Mentally Ill, who have Behaviour Problems, or who Offend. This noted that no consistent pattern of services has yet emerged, and that suitable alternatives included admission to a specialised mental illness unit in a mental handicap hospital, admission to a general psychiatric ward, admission to a small staffed house, or treatment by a community support team.

Audit in practice

The introduction of audit and resource management into medicine is closely linked with the introduction of computerised information systems. Substance abuse is an area where data collection is often difficult and the pressures of the clinical load may cause data collection to take second place. The need for information systems should not be allowed to impose an extra load on clinical staff or the effects of introduction can have severe negative consequences on units (McLean & Kaplan, 1983).

During 1991, only 0.54% of all admissions to All Saints Hospital (ASH) were under section 4 of the 1983 Mental Health Act (MHA) (England & Wales), representing 2.63% of all admissions under the MHA. These figures compare favourably with other published studies. This paper looks at possible reasons for these low figures and reports on an audit of those few admissions against the criteria laid down in the MHA.

L-tryptophan is an essential amino acid in human nutrition. The minimum daily requirement for adults is in the range of 175 to 250 mg daily and this is normally exceeded in the average western diet which contains 600 to 1000 mg. Excess tryptophan is normally metabolised through the kynurenine pathway and only 1–2% of tryptophan in the diet is converted to 5-HT. The concept that 5-HT had a part to play in depressive illness evolved after the original observation by Ashcroft & Sharman in 1960 that patients with severe depressive illness had lower levels of the metabolite of 5-HT in cerebrospinal fluid compared with controls. In addition, early papers on the therapeutic efficacy of tryptophan suggested that it was potentially as successful as ECT.

Training matters

Several trainees have described their experiences of training in community psychiatry (Lock, 1991; Malcolm, 1989; Naismith, 1989; Shah, 1991). Their reports indicate disadvantages as well as advantages in this type of training but are generally positive.

The “new deal” for junior doctors is set to ensure reduction of hours worked to a maximum of 72 per week by the end of 1996. To facilitate this reduction, juniors with a higher workload are being asked to consider alternative working patterns to the traditional “on-call” total system, and either work full shift systems (e.g. as in casualty departments) or a partial shift system that falls between these two extremes.

The Patients' Charter was introduced in 1991 (DoH, 1991). Although much maligned at the time and since, it has had positive effects. Much criticism was directed at the lack of resources to implement its generally laudable aims, e.g. reduced waiting times, and it was often dismissed – along with the Citizens' Charter as a whole – as a Tory pre-election stunt. The positive effects were to increase the awareness among patients and health professionals of standards to be aspired to. Personal experience has shown that awareness of the Patients' Charter extends to some of the most psychiatrically disabled patients in Nottingham. All doctors are aware of the Charter and many express regret that a Doctors' Charter of patient responsibilities does not also exist.

Forum

It was a day of quite intemperate heat as into our office in the Department of Applied Management Need burst an individual of some 40 years, perspiring as much, perhaps, from the heat and haste as the layers of clothing he affected. Beneath a pristine white coat he wore a pin-striped waistcoat and trousers, a starched shirt, striped tie and crimson kerchief fountaining from his breast pocket.

People's beliefs about illness, distress and disability profoundly influence their experience of, and responses to, such problems. Medical anthropologists have long recognised the importance of explanatory models of physical illness and the impact of these on the provision and use of health services. Similarly, psychological models of physical illness and related behaviour stress the importance of the ways in which people conceptualise or understand their difficulties. These are central in determining emotional responses to illness, help-seeking and illness-related behaviours, attitudes towards and compliance with treatment. Eisenbruch (1990) argues that, “the culturally constructed ideas held by the patient about the cause and nature of disease” are as important in relation to mental distress and disturbance. Help-seeking behaviour, attitudes towards and compliance with treatment are of central concern in psychiatry and all of these are influenced by people's understandings of their difficulties. Yet relatively little attention has been paid to the ways in which people conceptualise their mental distress.